|
I 'I —00g:200V
<br /> -QECrV ED
<br /> - ' 4,04...-F-etioll046'v'
<br /> 7 u
<br /> MAR 2 9 2019
<br /> , ...1,(1,,„ .c y5/eiii
<br /> MAH,c.,N COUNTY .
<br /> BUILDING INSPECTION
<br /> t Existing System Evaluation Report for Onsite
<br /> Ezilt-4,,,,
<br /> Wastewater Systems
<br /> DEO
<br /> State of Oregon Deportatortt of Emits:mental diallty
<br /> =4= `OnsitEiP1Pciratr
<br /> 1540i7ti
<br /> 1B5 East Seventh Ave,Suite 100 . .
<br /> Eugene;011-87401 • .
<br /> PlaakeantwarthefelloWing,que4ont comptetoly.Do not leave any blank re4ponies.Write unknown if
<br /> unknown.Refer to grCgOtiAdinipistrativeR0163407071-0105.fer more information,and please visit
<br /> 'btb3://www.menanoviateo/RestfientlatiPanesiSentTo-Smart.namt. .
<br /> Septic System Ownei‘,Reindded Information:
<br /> . '
<br /> Property Owner(a)(Sellers): ateilec_ t....e.MlAtffiitc ' Talepbolus:503'363-8155 ...
<br /> Site Address:2f 4 2-s-504/R.44,7te tot It : Avrora, zipcode,,,914ez
<br /> ;
<br /> git ,....
<br /> Camay: matitin Lot Size: ' AsneS'. . 'Feet(circle units)
<br /> Legal De:ter:idiom Ariff5 £i / (
<br /> ,..,
<br /> Age ofWasteWater treatm ,,l
<br /> ent oyrdint .-a (yess4 Is there a service contract for system components? MO
<br /> Datc.fire Optic teak re;1astpieFol.3•4 - 4(pleaseettich xteti9OfaVidlabley
<br /> Nugaber ofP59140'PCCOikft 6atilinA, -.2-- Italltide4let for boItIongbas,it bee:niece:it?
<br /> Was this secdcm completed by the evaluator because owner or agent was-Inenteil—able?
<br /> The above .,I: .athsa is true and to the best of my knowledge.
<br /> iek'vY-•:ifIrtgemzg__________
<br /> Date(Mlid/DD/YYYY) Signebue of Owner,or agent if present
<br /> Name of person performing evaluation(please print): *S.4.eve:.:-Funiiplipey
<br /> Certification:
<br /> I Installer 0 Professional Engineer
<br /> mithiten- mica Provider 0. linvhonmentallicalth Specialist
<br /> 9 N. ..........,,...i..... 0 Waste Water Specialist
<br /> Other:DEQ approved in writing(please descralsz) _
<br /> OntificationNumber:347574 1-7U 6 y .
<br /> . i
<br /> 13125bleSS name ',,,,, 1., ,, 1 VI 1 W :Antall ./11,1;i0.41111.et,r-‹atie12 44rnieth te I I. 1014A.
<br /> Business address
<br /> Po 1,10,f, 647 O /,011 eiy,,,... 0g „one SOS-WO-0Q e 0 •
<br /> r '
<br /> Date ofEvidnattort:; ''''' ' 0'.'": (MM/DDPIYYY)
<br /> 3 24. 14
<br /> Thereby certify,by my signaturs,that I meet all of the qualifications*aired to perfokin•MiSitaWaistewaier
<br /> system evaluations in the stats of Oregon pursuant to OAR 340-07i-0155. It 4
<br /> Dote(0,11DD( itrY), ' . Signature of QUidilled,S .-=,.-,,z.
<br /> Page 1 of 8 Updated 120/2016
<br />
|